Yoga Therapy Intake Form
Welcome to your journey with Yoga Therapy!

“I truly honor your commitment and desire to want to put in the work, look deep inside, and remember who you are in effort to heal and grow.” - Stefanie Jillian
Email *
Name
Phone Number
What times are you available?
Please select all that apply
Morning
Midday
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Explain Availability
What are your areas of concern?
Any other comments and/or questions?
Main Goal for Yoga Therapy or What Brings you to Yoga?
List any injuries
List any medications
Do you smoke tobacco?
Clear selection
Do you drink alcohol?
Clear selection
Do you use caffeine?
Clear selection
How well-rested do you feel after sleep?
Still Tired
Completely rested
Clear selection
Do you feel anxiety or stress?
Clear selection
Is there anything else I should know?
Have you ever practiced yoga or meditation before? *
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